Force-feeding

"Hunger strikes are relatively uncommon inside ICE detention. Last month, ICE began non-consensual feeding and hydration of numerous El Paso detainees after a federal judge issued a court order allowing them to be force-fed against their will. “ICE is committed to preserving the lives of those in its custody and maintaining orderly detention facility operations,” the agency said Thursday in response to the U.N.'s statement. “For their health and safety, ICE closely monitors the food and water intake of those detainees identified as being on a hunger strike. Medical staff constantly monitor detainees to evaluate whether the hunger strike poses a risk to the detainee’s life or permanent health.” While ICE doesn’t keep statistics on force-feeding throughout the immigration detention system, attorneys, advocates and agency staffers AP spoke with did not recall a situation where it had come to force-feeding. Federal courts have not conclusively decided whether judges must issue orders before ICE force-feeds detainees, so rules vary by district and orders are sometimes filed secretly. The controversy comes as President Donald Trump prepares to visit El Paso on Monday for his first campaign rally of the year to be held at a coliseum in the bustling border city. The detainees, who are refusing food to protest what they describe as verbal abuse and threats of deportation from guards, are being held in a highly guarded facility surrounded by a chain-link fence on a busy street near the airport."

"Force-feeding raises ethics issues for medical professionals who work inside ICE facilities. The American Medical Association has expressed its concerns about physicians participating in the force-feeding of hunger strikers on multiple occasions, and its own principles of medical ethics state “a patient who has decision-making capacity may accept or refuse any recommended medical intervention.” The association also endorses the World Medical Association Declaration of Tokyo, which states that when prisoners refuse food and physicians believe they are capable of “rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially.”"

"When a Palestinian man in Israeli custody came close to death this week, doctors challenged an Israeli law. Palestinian prisoner Mohammad Allan was in critical condition after he had refused food for two months, protesting his detention since last November in Israeli custody. Suspected of ties to a militant group, he was held with no charges, no lawyer and no accusations to face in court. Six weeks into his hunger strike, Israel's parliament passed a law permitting the force-feeding of prisoners in order to keep them alive. Allan might have become a test case for the law, but doctors made it clear they would not participate, calling it unethical medical treatment. "It's like rape," says Yoel Donshin, a retired anesthesiologist and a member of Physicians for Human Rights. "You will ask a physician to rape a patient for treatment? This is unacceptable." Donshin doesn't believe Israeli politicians who supported the law want to save the lives of prisoners. "They do not care for the welfare of the prisoners," he says. "They just want him not to become a symbol or martyr.""

"Mohammad Allan's situation was different. Solo, and much closer to death, Palestinian protests over his continued detention grew as his health got worse. Israeli authorities feared his death could trigger street violence. But amid the turbulent public debate, one lawmaker who had voted against allowing force-feeding said he changed his mind. Yaakov Peri also used to head Israel's internal security. "The only solution is that he be fed," said Peri on an Israeli radio program last Wednesday. "I was against the force-feeding bill, but the alternative is an end to his life. There are times when the state of Israel has to make a decision, and if we need to force-feed him, we will have to force-feed him." He spoke before an Israeli high court ruling that ended the question of force-feeding Allan. The court suspended his detention until doctors could determine any long-term health consequences and Allan agreed to take nutrients."

"Israel's public security minister opposed the ruling. He warned that more Palestinian prisoners will now go on extreme hunger strikes and, on his Facebook page, criticized the doctor who heads the Israel Medical Association for telling physicians to ignore the new Israeli law. (Updated 1:30 p.m., Aug. 24: On Sunday, four days after the court ruling, Israeli media reported that more than a dozen well-known Israeli academics and physicians signed a paper supporting the state's position, saying a doctor's responsibility is to save lives). That doctor, Leonid Eidelman, says he did nothing wrong. "It's not breaking [the] law because there is no law in Israel to force doctors to use a treatment they don't believe should be used," he said. Under Israel's force-feeding law, a judge can allow, but not order, a doctor to participate. Israel is not the only place force-feeding is an issue. The U.S. military has repeatedly force-fed hunger strikers held at Guantanamo Bay, and American courts have upheld the practice."

"In Israel, Eidelman and other physicians say they would honor a patient's wish to refuse food, but would step in to save that same patient's life if he or she were unconscious. Eidelman says that worked for Mohammad Allan, who wanted a trial or freedom — not death. "And in this case actually, it was proven. Because after he was resuscitated he regained his consciousness and didn't regret that he was resuscitated." Mohammad Allan ended his hunger strike after the Israeli court ruling. The force-feeding law remains on the books, awaiting a future case and a future debate with Israel's doctors."

"Manual restraint, a type of physical restraint, is a common practice in inpatient mental health settings linked to adverse physical and psychological staff and patient outcomes. However, little is known about the use of manual restraint for compulsory nasogastric feeding of patients with anorexia nervosa within inpatient eating disorder settings. The present phenomenological study aimed to explore nursing assistants’ experiences of administering manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa. The study followed COREQ guidelines. Eight semi-structured interviews were conducted with eight nursing assistants from one UK inpatient child and adolescent eating disorder service. Interviews were transcribed verbatim and analysed using Thematic Analysis. Three themes were extracted: An unpleasant practice, Importance of coping, and Becoming desensitised and sensitised. Nursing assistants commonly experienced emotional distress, physical exhaustion, physical injury and physical aggression as a result of their manual restraint use. Nursing assistants appeared to cope with their distress by talking with colleagues and young persons who were further in their recovery, and by detaching themselves during manual restraint incidents. The findings highlight that the use of manual restraint for compulsory nasogastric feeding of young persons with anorexia nervosa in the UK, is a highly distressing practice for nursing assistants. It is therefore important that sufficient supervision, support and training is made available to staff working in these settings."

"Manual restraint is a form of physical restraint practice, used particularly within inpatient mental health settings, whereby one or more persons restrict the movement of another by manually holding them (Stewart et al., 2009; Stubbs & Paterson, 2011). This differs from mechanical physical restraint which refers to the use of devices (e.g., belts or cuffs) to restrict movement (Care Quality Commission, 2018). Manual restraint is commonly used in conjunction with seclusion and chemical restraint to prevent harm to patients and staff, or to administer medications and other treatments (Chapman et al., 2016; Hawkins et al., 2005; Ryan & Bowers, 2006). For instance, the literature has highlighted the use of manual restraint in response to patient self-harming, aggressive and attempted absconding behaviours (Bowers et al., 2015), and patient medication refusal (Owiti & Bowers, 2011). Concerns have been raised about manual restraint use (Mind, 2013), and internationalguidelines and programmes advocating for its reduction have emerged (e.g., Department of Health, 2014; Mental Health Commission, 2014; O’Hagan et al., 2008; Royal Australian and New Zealand College of Psychiatrists, 2016). Within England alone, over 50,000 incidents of manual restraint were recorded between the years of 2016 and 2017 in National Health Service funded secondary mental health, learning disability (LD) and autism services (Collinson, 2017), demonstrating the commonality of manual restraint practice. This study explores nursing assistants’ experiences of administering manual restraint for compulsory nasogastric feeding (CNF) of young persons with anorexia nervosa (AN)."

"The literature has highlighted the numerous adverse physical and psychological staff outcomes as a result of manual restraint use. Staff have reported experiencing physical exhaustion, physical pain and injury, and numerous unpleasant emotions (e.g., anxiety, fear, anger) as a result of administering manual restraint (Bigwood & Crowe, 2008; Bonner et al., 2002; Chapman et al., 2016; Sequeira & Halstead, 2004; Wilson et al., 2017). Manual restraint has also been linked to staff feelings of internal conflict, as staff may perceive the act of manually restraining patients as incongruent with their therapeutic role (Bigwood & Crowe, 2008; Chapman et al., 2016; Sequeira & Halstead, 2004; Wilson et al., 2017). Although manual restraint is commonly administered within inpatient mental health settings (Stewart et al., 2009; Wilson et al., 2017), the literature has also illustrated its use within the emergency department, LD services, and paediatric general hospital and residential childcare settings (Chapman et al., 2016; Fish & Culshaw, 2005; Lombart et al., 2019; Steckley & Kendrick, 2008; Svendsen et al., 2017). The manual restraint of young persons raises ethical and moral issues for staff, and this has been evidenced by the distress and internal conflict staff may experience when manually restraining young persons (Lombart et al., 2019; Steckley & Kendrick, 2008; Svendsen et al., 2017). For instance, staff have reported feeling guilty when restraining children for medical procedures, with some describing how “difficult and demanding” the process can be (Lombart et al., 2019; Svendsen et al., 2017). Presently, little research has been conducted on the use of manual restraint within child and adolescent settings. However, even less research has been conducted on the use of manual restraint for CNF of patients with AN within inpatient eating disorder settings."

"AN is an eating disorder characterised by an extremely low body weight, a severe restriction of food, a strong desire to be thin, and an intense fear of gaining weight (National Institute of Mental Health, 2018). Under relevant mental health legislation, patients with AN can be administered CNF in extreme cases when they are presenting with very low body weight, and refusing to eat and/or drink (Fuller et al., 2019; Royal College of Psychiatrists, 2014). In the rare case when a patient is resistant to nasogastric feeding, staff members may administer manual restraint to ensure the safety of themselves and the patient during feeding (Fuller et al., 2019, 2020; Neiderman et al., 2001). Within the UK, manual restraint in this context may be used in the absence of other restrictive practices (e.g., seclusion), and may involve holding the patient’s arms, legs and head in a safe position, in order to allow for the safe passing of a nasogastric tube and subsequent feeding (Fuller et al., 2019; Neiderman et al., 2001). Feeding in the context of active resistance is a rare event and raises ethical, legal and clinical issues for all those involved (National Collaborating Centre for Mental Health, 2004). Despite the wealth of research that exists on the treatment of AN, we could only locate one published qualitative study that explored the experience of CNF in the context of AN, including the experience of CNF under manual restraint (Neiderman et al., 2001). In this qualitative survey study exploring children and adolescent patients’, and their parents’ experiences of nasogastric feeding, the authors summarised patients’ nasogastric feeding experiences into two main categories: “I regretted it at the time but think that it was necessary” and “I hated it then and hate it now”. This study however did not focus specifically on the practice of CNF under manual restraint, and did not use in-depth qualitative data collection methods such as individual interviews (the authors used qualitative questionnaires). Studies specifically exploring the experience of CNF under manual restraint from either the patient or staff member’s perspective using in-depth data collection methods, could provide valuable insight into this under-researched practice."

"Within the UK, it is common for graduates of non-nursing degrees (e.g., psychology) who are wishing to pursue a career in mental health (e.g., clinical psychology) to first start out working as healthcare and nursing assistants in mental health settings to gain relevant clinical experience."

"Participants were recruited from a private 25-bed locked inpatient specialist child and adolescent eating disorder service in the UK which provides inpatient treatment to young persons aged 9-18 years with eating disorders. In addition to providing multidisciplinary input from a number of professionals including psychiatrists, paediatricians, psychologists, family therapists and dieticians, the eating disorder service, under the powers of the Mental Health Act 1983 (Department of Health, 2015), and occasionally parental consent, also provides CNF under manual restraint as an intervention to young persons with AN presenting with ongoing food and/or fluid refusal and subsequent non-compliance with nasogastric feeding. A standard CNF intervention under manual restraint within the eating disorder service could typically last between 10 and 30 minutes, and involve up to five nursing assistants restraining the young person in the seated position, and up to two registered mental health nurses inserting the nasogastric tube, checking the tube’s placement, and delivering subsequent dietary nutrition through the tube via syringe. As reported by participants, up to 12 CNF interventions under manual restraint could occur per shift within the eating disorder service. This was owing to the fact that some young persons had care plans in place for pre-planned CNF interventions under manual restraint to be implemented multiple times per day (e.g., at specific times during the mornings, afternoons and evenings) due to their global and ongoing refusal of all foods and fluids, and their non-compliance with nasogastric feeding. Chemical restraint was not routinely used within the eating disorder service, and there was a service policy in place for CNF interventions under manual restraint to be aborted and reattempted at a later time in circumstances where it was not possible to safely administer nasogastric feeding within 30 minutes of manual restraint holds being applied."

"Three themes were extracted from the analysis: An unpleasant practice, Importance of coping, and Becoming desensitised and sensitised. It is important to consider these themes in relation to the 5-36 month difference within the experience level of nursing assistants."

"An Unpleasant Practice Administering manual restraint for CNF of young persons with AN was an unpleasant practice for all nursing assistants, and this was evidenced by the numerous reported adverse physical, psychological and interpersonal outcomes. Some felt that they did not receive enough support from the eating disorder organisation in managing these outcomes. Six subthemes are reported. Emotional distress. Despite recognising the necessity of CNF under manual restraint for young persons with AN who were refusing all foods and/or fluids, seven of the eight nursing assistants described the emotional distress they experienced as a result of administering manual restraint. Some described the practice as “traumatising” both for themselves and the young person; this was predominately attributed to the coercive nature of the practice and the young person’s distressing response to it, which typically included active resistance, aggression, screaming, coughing, complaints of discomfort, and occasional nasal bleeding from nasogastric tube insertion: It’s scary, it’s emotionally draining for both the patient and staff . . . there’s blood coming out [from the young person’s nose], the child is screaming down the place, so as much as you’re supporting the child, it becomes very difficult because it seems like you’re either attacking or physically punishing somebody. (Participant 2) Seven nursing assistants reported experiencing a range of unpleasant emotions as a result of applying manual restraint for CNF. Anxiety, guilt and anger were commonly cited emotions. Participants felt anger, often, in response to being hurt by the young person during restraint, and the young person’s lack of cooperation. Anxiety and guilt were commonly attributed to the unpredictability and coerciveness of manual restraint respectively: Before I go into a restraint, my heart starts pumping a bit more . . . I feel very anxious because we don’t know what could happen. (Participant 4)"

"Physical exhaustion. All nursing assistants described the physical exhaustion they felt in relation to applying manual restraint for CNF, especially in circumstance where the young person was highly resistive. There were multiple manual restraints to perform per shift, and reports of sweating during restraints were not uncommon. At times, the manual restraint continued even after nasogastric feeding had been completed because the young person was either trying to self-harm or purge the liquid supplement they had just been given. This made the whole restraint even more tiring for participants: Once you’ve been in a restraint in a feed you just want to be done with it because it’s a physical thing, your body’s tired, you’re hot and sweaty, you’re covered in their sweat as well . . . and if someone continues it by trying to purge, it’s more tiring than anything else. (Participant 5) Despite the physical exhaustiveness of using manual restraint, all nursing assistants also reported that the restraint of some young persons involved minimal physical exertion because of their increased compliance and preference to be fed under restraint: I was restraining her arm and one of her legs, and it wasn’t very intense. The patient was going through this process for a very long time, so she was at that stage where she wanted this holding let’s say, but she wasn’t aggressive or very resistive. (Participant 1) Once you’ve been in a restraint in a feed you just want to be done with it because it’s a physical thing, your body’s tired, you’re hot and sweaty, you’re covered in their sweat as well . . . and if someone continues it by trying to purge, it’s more tiring than anything else. (Participant 5)"

"Patient aggression. All nursing assistants frequently reported being subjected to physical and/or verbal aggression by some young persons during manual restraint use. It appeared from their accounts that these young persons were using whatever means they could, to prevent or stop the restraint, in order to stop or avoid nasogastric feeding. Commonly cited verbal aggression included swearing and shouting. Commonly cited physical aggression included spitting, kicking, scratching, biting, punching and head-butting. Some participants reported being subjected to such physical aggression even when nasogastric feeding had been completed: We were starting to leave the restraint . . . I was doing the lower part of the legs and I was kind of tilted over and she actually head-butted me on the head . . . the feed’s finished but she still lashes out at staff. (Participant 4) Being on the receiving end of physical aggression elicited reciprocal urges of aggression for two nursing assistants. These urges were cited in the context of self-defence and the participants in question were clear that they did not reciprocate aggression in any form: One of the patients was trying to dig her nails in my skin and rip whatever I was wearing to protect my arms. . . I hate these moments particularly because I feel I want to hurt the child . . . at that moment you want to hurt them in order to protect yourself. (Participant 1)"

"Physical injury. All nursing assistants reported sustaining frequent physical injuries as a result of applying manual restraint for CNF. Injuries typically ranged from back pains to bruises and were reportedly sustained by the physical aggression of young persons or through the execution of the manual restraint itself: When the patient was moving, as we were restraining her, I got thrown at a door handle and that caused quite big bruising on my back. (Participant 8) Some nursing assistants reported only becoming aware of a sustained injury after they had returned home from their shift: Sometimes it happens with bruises, like you go home, you haven’t realised how you might have sustained this bruise and then you realise . . . or you might feel back pains which you don’t really realise when you’re in the restraint. (Participant 6) In addition to back pains and bruises, two participants reported that they had either obtained, or had witnessed their colleagues obtain more severe physical injuries during manual restraints such as dislocated shoulders, head injuries and being kicked in the groin. In all reported instances this was due to the physical aggression of a young person: For some reason, one of the legs had not been held tightly, and she kicked the nurse who fell over and landed down. That was very scary because the staff banged her head and she got unconscious . . . they had to call an ambulance. (Participant 2)"

"Pressure and responsibility. Six of the eight nursing assistants voiced feeling pressured and responsible for their colleagues and themselves while applying manual restraint for CNF. These participants appeared to attribute these feelings to their manual restraint performance, which could have a direct impact on their colleagues’ ability to effectively restrain, and the overall success of the nasogastric feeding procedure: You know in every restraint that if you lose your grip and they get a hand through or a leg through, the whole thing’s going to go wrong, so you feel responsible . . . If you lose their hand, they’ll grab the tube out and then the whole process has to start again . . . you feel the responsibility from all the other staff as well. (Participant 7) Failure to execute or maintain restraint positions could result in feelings of frustration and failure, and this was explicitly expressed in four nursing assistants’ interviews. It appeared that these participants placed a great deal of pressure and responsibility on themselves to execute their designated manual restraint positions."

"Importance of Coping Seven of the eight nursing assistants valued coping, and this was evidenced by the strategies they consciously employed which helped them cope with applying manual restraint for CNF. Coping strategies were typically utilised during and after manual restraint use. Two subthemes are reported."

"Detaching the self. Five of the eight nursing assistants reported actively detaching themselves from the process when they were administering manual restraint for CNF. This was predominately described by female nursing assistants and was evidenced through the use of terms such as “zoning out”, “shutting off” and “taking my mind off”. Detaching the self appeared to be a conscious response used by participants to cope with the adverse psychological outcomes of manual restraint use: I sort of try to stay focused on what I’m doing during the whole process but sort of try to take my mind out of this as well so that I can cope with it because it’s a very stressful procedure so I’m trying to think of something more calming. (Participant 1) I get to a point when I just shut off and then I’m just staring into nowhere and just trying to remain in the restraint position because it’s just too much to take in. (Participant 8) For one nursing assistant, detaching the self was a “necessary” coping strategy that guarded against the adverse psychological outcomes that could result from paying attention to the young person’s distress during restraint. Failing to “zone out”, in this participants view, was self-destructive: It becomes quite emotionally damaging to pay attention too much to what the patients are screaming and shouting about in the feed so I prefer to kind of zone out, it’s my coping mechanism . . . it’s necessary to zone out and I kick myself if I don’t do it because it’s just self-destructive not to. (Participant 5)"

"Talking with others. Six of the eight nursing assistants reported seeking out conversations with their colleagues and young persons who were further in their recovery, after they had been involved in a manual restraint for CNF. For some participants, this appeared to be a method of cheering up through humour: Sometimes you just need to get away and be lifted up by someone else. If you can bounce off of a staff member it’s pretty good...or go to some of the hyper kids, the kids that at the moment are really doing well, and if they’re all having banter with each other, you can sort of get brought into it and sometimes you just forget what’s just happened in the restraint. (Participant 5) For other participants conversing with their colleagues was a method of “venting out” after a particularly challenging restraint which had elicited feelings of frustration: You can vent out amongst each other as the people that have done the restraint. (Participant 3) Four nursing assistants reported seeking out trusted staff members to confide in. For the majority of these participants this was a method of expressing their feelings, especially in circumstances where they had partaken in a restraint that had upset them: . . . and then I spoke to a member of staff that I trusted in that situation and it turned out that the same thing had happened to her so it was nice to have that understanding, it made me feel much less alone. (Participant 7)"

"Becoming desensitised and sensitized Despite the physical and emotional challenges that encapsulated participants’ experiences of administering manual restraint for CNF of young persons with AN, and unlike the “Importance of coping” theme which described participants’ conscious attempts to cope with the procedure, five of the eight nursing assistants reported becoming emotionally desensitised to the practice over time. This was an adaptation predominately reported by male nursing assistants through descriptions such as “getting used to it”, becoming “desensitised” and becoming “immune”: We’re kind of immune to the screams, the noises, the fighting, the everything so it’s much easier nowadays, if it’s done properly and you’re not being hurt, it’s easy to go through a restraint without feeling very guilty that you’re doing anything wrong. (Participant 2) For some nursing assistants, this familiarity to the practice of applying manual restraint for CNF appeared to be facilitated by a change in their attitudes towards the practice over time. This attitude change appeared to involve the acceptance of CNF under restraint as something that was necessary, either as part of their job role or for the young person’s own safety: Now it’s just what needs to be done, it’s what needs to be done because the patient is not taking the responsibility of feeding themselves so we have to take on that responsibility. (Participant 4) In contrast to becoming desensitised, two nursing assistants reported that they had become emotionally sensitised to the manual restraint procedure. Participating in the restraint had become more emotionally challenging for these participants over time due to the therapeutic relationship they had built with the young person over time: The first restraints were a lot easier because I didn’t have a connection with the patients, whereas the later on it’s got, the more connection I have with the patients, the more worried I am, and the more emotionally demanding it is. (Participant 5)"

"The purpose of this phenomenological study was to explore nursing assistants’ experiences of administering manual restraint for CNF of young persons with AN. The findings paint a physically and emotionally distressing picture of the participants’ experiences and provide valuable insight into the experience of applying manual restraint for CNF of patients with AN. It is clear from the analysis that administering manual restraint for CNF of young persons with AN was a distressing practice for nursing assistants. The practice elicited numerous unpleasant emotions including anxiety, guilt and anger, and a small number of participants described becoming emotionally sensitised to the practice over time. Although the majority of participants expressed becoming emotionally desensitised to the manual restraint procedure, their accounts were often contradictory, suggesting that they had not necessarily become desensitised to the practice. These findings are in line with that of previous studies of staff’s manual restraint experiences in both child and adolescent, and adult consumer settings, which have also highlighted the experience of distress and numerous unpleasant emotions as a result of administering manual restraint (e.g., Bigwood & Crowe, 2008; Bonner et al., 2002; Chapman et al., 2016; Lombart et al., 2019; Sequeira & Halstead, 2004; Steckley & Kendrick, 2008; Svendsen et al., 2017; Wilson et al., 2017). It is not surprising that the theme “Importance of coping” was extracted from the analysis, given the illustrated adverse physical and psychological staff consequences that could result from applying manual restraint for CNF of young persons. The majority of nursing assistants described consciously detaching themselves from manual restraint incidents as a means of coping with the distress it elicited. Detaching oneself appeared to serve a protective function for participants, somewhat safeguarding them against the experience of distressing emotions; this is in line with the findings of previous studies in both child and adolescent, and adult consumer settings which have highlighted how some staff “switch off” their feelings or “temporarily suspend” their ability to empathise with patients during manual restraint incidents (Lombart et al., 2019; Sequeira & Halstead, 2004). Talking with colleagues and young persons who were further in their recovery were also cited by nursing assistants as coping strategies. These strategies appeared to help nursing assistants regulate their emotions through humour (e.g., “banter”), and through cathartic processes (e.g., “venting out”). Staff participants from previous studies of manual restraint within adult mental health settings have similarly highlighted the importance of colleague support in coping with restraint use (Bigwood & Crowe, 2008; Bonner et al., 2002; Sequeira & Halstead, 2004). However, this finding has not been explicitly reflected in studies within child and adolescent settings (e.g., Lombart et al., 2019; Steckley & Kendrick, 2008; Svendsen et al., 2017)."

"By far the most prevalent finding in this study concerned the adverse physical outcomes that pervaded nursing assistants’ experiences of administering manual restraint for CNF of young persons with AN. Nursing assistants were subjected to frequent physical aggression by some young persons, they sustained physical injuries from being physically abused and from executing manual restraints, and they were often physically exhausted from applying manual restraint, typically multiple times during each shift. These findings are in line with previous studies of manual restraint within adult consumer settings which have highlighted the commonality of staff injuries during manual restraint use (Chapman et al., 2016; Lancaster et al., 2008; Southcott & Howard, 2007; Wilson et al., 2017), the physical exhaustion associated with administering manual restraint (Hawkins et al., 2005), and the patient physical aggression staff may be subjected to during manual restraint incidents (Wilson et al., 2017). However, with the exception of one study which reported staff physical exhaustion (Lombart et al., 2019), these findings have not been reflected in previous studies of manual restraint within child and adolescent settings. An important finding in this study concerned the interpersonal challenges that the majority of nursing assistants reported experiencing including staff conflict, and feelings of pressure and responsibility. In almost all cases, the former and latter experiences were associated with manual restraint performance, that is, the nursing assistants’ effectiveness at executing their designated manual restraint positions. Although these findings have not been explicitly reflected in previous studies of staff manual restraint experience, two of the participant extracts in one study within an adult mental health setting, were illustrative of the feelings of pressure and responsibility described by participants in this study (e.g., “they were all there watching, and I am thinking Oh God, have I done this right”; Bigwood & Crowe, 2008, p. 219)."

"In light of the findings of this study, it is crucial that eating disorder services providing CNF under manual restraint sufficiently support their frontline nursing staff. Support can include the implementation of policies ensuring that manual restraints are spread out fairly between nursing staff, so that the same staff members are not repeatedly involved in manual restraint incidents. Support can also include, access to adequate manual restraint training and refresher training, access to adequately sized and ventilated ward areas/rooms for administering manual restraint for CNF, and access to sufficient supervision, post-restraint debriefing, reflective sessions, and talking therapy. Under the close working between psychiatrists, physicians and anaesthetists, it would also be reasonable for relevant eating disorder services to consider the supplementary risk-assessed use of chemical restraint (e.g., oral and parenteral benzodiazepines and oral olanzapine) and mechanical restraint (e.g., restraining belts and soft cuffs) in extreme cases where patients present with ongoing extreme levels of physical aggression and resistance to staff during manual restraints for CNF (Ridley & Leitch, 2019; Royal College of Psychiatrists, 2012, 2014). The aforementioned points are particularly important given the risk of burnout, compassion fatigue and physical injury which may lead to high staff turnover and sickness, and poor standards of care if left unresolved."

"It is critical that relevant eating disorder services prioritise the use of psychological interventions, and alternatives to CNF interventions under manual restraint where practically possible, given the highly distressing impact this practice may have on both nursing staff and patients. This can include offering a range of psychological interventions (e.g., art, family, individual and group therapy, etc) and dietary choices to patients (e.g., diverse food types, liquid supplements, etc), with such options frequently being re-communicated to patients who refuse them. The provision of staff training in communication and trauma-informed approaches may help nursing staff develop improved therapeutic relationships with patients (Maguire & Taylor, 2019), which in turn may have an impact on patients’ receptiveness towards staff support, their willingness to accept dietary intake, and in turn, their recovery from AN (Sly et al., 2013). CNF interventions under manual restraint should only be used as a last resort after exhaustive unsuccessful attempts have been made to offer oral dietary intake to patients, and there is a clinical need for feeding. This is particularly important for patients who present with ongoing refusal of significant dietary intake, where there may be a risk of the habitual use of manual restraint for CNF as a first resort intervention rather than a last resort. The findings of this study can be used as a useful source of information for relevant eating disorder services, to illustrate the potential adverse physical, psychological and interpersonal challenges that administering manual restraint for CNF of patients with AN, could pose to their nursing staff. The findings from this study could also be used as a reference for manual restraint for CNF training programmes to highlight the challenges this practice may pose to trainees."

"The participants in this study were recruited from a single inpatient eating disorder service in the UK, meaning that their experiences are likely to have been specific to this service. Caution is thus needed when transferring the findings of this study to other inpatient eating disorder settings. Further research exploring the phenomenon of CNF under manual restraint within different inpatient eating disorder services would be valuable in clarifying the extent to which the experience described in this study is common. The first author [MK] had lived experience of administering manual restraint for CNF of patients with AN, and conducted all interviews and performed data analysis. Although he maintained a descriptive phenomenological stance throughout, kept a reflexive diary, and made revisions to the analysis following discussions with [JM] and [NS] who both had no lived experience of manual restraint, his lived experience is likely to have had some influence on the analysis. However, we employed member checking to improve credibility, and all our participants expressed that the analysis had accurately captured their experiences. Notwithstanding, it may be beneficial for future research exploring staff’s experiences of CNF under manual restraint to be conducted by researchers who do not have lived experience of this practice, in order to reduce potential bias. The participants in this study were nursing assistants and thus were not registered nurses. Consideration thus needs to be taken into account of how this participant group may differ to registered nurses, for example, in their training, experience, duties and levels of responsibility. Although the majority of our participants were educated to degree or masters level in related subjects such as Psychology and Biology, and were supervised by registered mental health nurses (so it is likely that they possessed adequate clinical knowledge and skills), the aforementioned points still need to be taken into consideration when transferring the findings of this study to other inpatient eating disorder settings. Participants all volunteered to participate in this study. Therefore, they were self-selected. Consequently, the participants may have potentially represented those who were more vocal or those with more negative or positive experiences. This needs to be taken into consideration when interpreting the findings of this study."

"To our knowledge, this study is the first to explore nursing assistants’ experiences of administering manual restraint for CNF of patients with AN, and makes a substantial contribution to the limited literature on this practice. The findings highlight that the use of manual restraint for CNF of young persons with AN is a highly physically and emotionally distressing practice for nursing assistants. It is therefore important that sufficient supervision, support and training is made available to staff working in these settings."

"Eating disorder services that provide CNF under manual restraint as an intervention need to ensure that their frontline nursing staff have access to sufficient support, supervision and training at a minimum, given the adverse physical and psychological staff outcomes that may result from this practice. Such eating disorder services also need to have policies in place that ensure that manual restraints for CNF procedures are spread out fairly amongst staff, especially in services in which this intervention is frequently used."

"This case presents the question of whether the state may force-feed an inmate engaged in a hunger strike. There appears to be no recorded Connecticut decision on point.[1] The plaintiff, Theresa C. Lantz, is the current commissioner (commissioner) of the department of correction (department). The defendant, William B. Coleman, is a sentenced prisoner, under the care of the department. He was convicted, after a jury trial, of sexual assault in a spousal relationship and unlawful restraint in the first degree. In May, 2005, he was sentenced to fifteen years imprisonment, execution suspended after eight years. His maximum discharge date is December 30, 2012."

"On January 9, 2008, the plaintiff filed a verified complaint, seeking both a temporary and permanent injunction to allow the department to force-feed the defendant. On January 14 and 23, 2008, the court held an evidentiary hearing on the application for a temporary injunction. At the conclusion of the evidence, the court heard oral argument from counsel for each party and, because of the exigent circumstances, issued an order orally. The court issued a temporary injunction authorizing the department to provide the defendant with intravenous fluids or nasogastric feeding and other necessary health care measures, even by means of reasonable force, and enjoining the defendant from interfering with same. The court's findings and reasoning were deferred to this subsequent written decision."

"Ducate has experience with hunger strikes, and ending them, on six occasions in Texas. She indicated that the preferred means of feeding an inmate on a hunger strike is to sedate the prisoner, insert a nasogastric tube into his stomach, via the nose and throat, and then pipe nourishing liquid directly into the stomach. It is not a medically difficult procedure, and, in her experience, inmates who are so fed begin to eat normally soon thereafter. On the basis of her experience with hunger strikes in Texas, she believes that such incidents have a serious and detrimental effect on the other inmates. In her experience, inmates look to the department for their care and would be shocked if an inmate was allowed to kill himself without intervention. She adds that a hunger strike has a detrimental impact on prison safety and security. In this case, where the defendant is in the infirmary full-time, it leads directly to mentally ill prisoners being transferred to other facilities, away from treatment teams familiar with them, because this inmate is taking an otherwise available bed for his self-induced hunger strike."

"Edward Blanchette, an internist, is the clinical director for the department. He has examined the defendant from a physical aspect and has been monitoring his condition since the end of last September. He reviews the defendant's medical records thrice weekly and has met with him twice. The defendant has been taking only liquids, those being water, some juice and some milk. Although the defendant is adequately hydrated, he is taking insufficient calories to sustain himself. The defendant has already suffered muscle wasting and anemia but, by taking some milk, has slowed the speed of his deterioration. Blanchette testified that as of January 14, the defendant could cause himself serious physical damage within one month, and be in dire straits. Risks include the possibility of heart arrhythmia due to electrolyte imbalance, a life threatening situation. A sustained hunger strike will lead to kidney and liver failure, and eventually to death. Blanchette opined that the timing of such deterioration is not subject to precise calculation by a physician or fine-tuning by an inmate. He stated that it is unusual for an inmate to engage in a protracted hunger strike, such as the defendant's. Brian K. Murphy, deputy commissioner of operations for the department, who is responsible for supervision of all inmates and is a career department employee, testified as to the impact of a hunger strike on the inmate population. Murphy has risen, in twenty-six and one-half years, from a correctional officer to his present position, always with direct supervision of inmates. He became aware of the defendant's hunger strike last September and has been following it since, including meeting with the defendant. The department has taken no disciplinary action of any kind against the defendant for his hunger strike. On more than twenty past occasions, Murphy has had to deal with hunger strikes. He is adamant that there are no secrete in prisons, that inmates rely on the department to intervene to protect inmates from self-harm and that the defendant's death from a hunger strike could cause unrest, including demonstrations and physical violence. There is also the risk of copycat hunger strikes to manipulate the prison system, should the defendant's hunger strike continue."

"In State ex rel. Schuetzle v. Vogel, 537 N.W.2d 358, 360-61 (N.D.1995), the Supreme Court of North Dakota determined that the state could force-feed and administer insulin to a diabetic prisoner who refused to eat or take medicine. Finding that the prisoner attempted this to "manipulate the system and ... blackmail ... prison officials"; (internal quotation marks omitted) id., at 360; the court ruled that "the state's interest in orderly prison administration is the controlling factor here...." Id., at 361. This issue has arisen in federal cases in the specific context of civil contemnors trying to circumvent the judicial process. A civil contemnor being held for refusing to testify before a grand jury went on a hunger strike for political and religious reasons. In re Grand Jury Subpoena John Doe v. United States, 150 F.3d 170, 171 (2d Cir.1998) (per curiam). In a very brief opinion, the court held that "the district court's force-feeding order ... does not violate a hunger-striking prisoner's constitutional rights.... Although Doe, as a civil contemnor, has been convicted of no crime, the institution where he is housed is still responsible for his care while incarcerated. Other compelling governmental interests, such as the preservation of life, prevention of suicide, and enforcement of prison security, order, and discipline, outweigh the constitutional rights asserted by Doe in the circumstances of this case." Id., at 172. The United States District Court for the Southern District of New York has also addressed this issue in the context of a civil contemnor, focusing on preventing the contemnor from undermining the judicial process. In re Sanchez, 577 F.Supp. 7 (S.D.N.Y.1983). The court held that "Sanchez is, by his own admission, attempting to bring maximum pressure to bear upon the Judge who will ultimately rule upon his motion to vacate the contempt order. Moreover, the prolongation of this hunger strike will soon render Mr. Sanchez physically or mentally incapable of testifying before the grand jury, thereby rendering further coercive sanctions futile. In one sense, therefore, Mr. Sanchez is attempting to escape from prison and to frustrate the lawful authority of the courts. This is a purpose that we cannot condone." Id., at 9."

"In contrast, three courts have decided that the state has no right to force-feed an inmate. The Supreme Court of Georgia affirmed a trial court's decision to deny the state's petition to force-feed a hunger striking inmate. Zant v. Prevatte, 248 Ga. 832, 286 S.E.2d 715 (1982). In so doing, the court considered that "[the inmate] is not mentally incompetent, nor does he have dependents who rely on him for a means of livelihood. The issue of religious freedom is not present. Under these circumstances, we hold that [the inmate], by virtue of his right of privacy, can refuse to allow intrusions on his person, even though calculated to preserve his life. The State has not shown such a compelling interest in preserving [the inmate's] life, as would override his right to refuse medical treatment." Id., at 834, 286 S.E.2d 715. The state did not claim any of the traditional factors except a duty to preserve the inmate's health and life. In 1993, the Supreme Court of California determined that the state had no authority to interfere with an inmate's hunger strike. Thor v. Superior Court, supra, 5 Cal.4th 725, 21 Cal.Rptr.2d 357, 855 P.2d 375. The court's holding specified that "under California law a competent, informed adult has a fundamental right of self-determination to refuse or demand the withdrawal of medical treatment of any form irrespective of the personal consequences." Id., at 732, 21 Cal.Rptr.2d 357, 855 P.2d 375. The court further stated that "[u]nder the facts of this case, we further conclude that in the absence of evidence demonstrating a threat to institutional security or public safety, prison officials, including medical personnel, have no affirmative duty to administer such treatment and may not deny a person incarcerated in state prison this freedom of choice." Id."

"Thor involved a prison physician petitioning the court to allow him to force-feed a quadriplegic patient who had decided to die. Id. The court considered four state interests: preserving life; preventing suicide; maintaining the integrity of the medical profession; and protecting innocent third parties. Id., at 737, 21 Cal.Rptr.2d 357, 855 P.2d 375. Finally, the court considered how this would affect orderly administration of the prison system. Id., at 744, 21 Cal.Rptr.2d 357, 855 P.2d 375. In considering the first four factors, the court, noted that this patient was quadriplegic and serving a life sentence; the patient's decision to refuse medical treatment was an informed decision, and there were no other persons involved in this decision. Id., at 743-44, 21 Cal.Rptr.2d 357, 855 P.2d 375. Finally, the state had presented no evidence on the effect this would have on administration of the prison system. Id., at 745, 21 Cal.Rptr.2d 357, 855 P.2d 375. The third case prohibiting state interference with a prisoner's hunger strike is from Florida. The inmate went on a hunger strike to protest his transfer to a different prison and to protest the lodging of complaints against a prison chaplain. Singletary v. Costello, 665 So.2d 1099, 1101 (Fla.App.1996). The court first recognized a strong interest in the inmate's rights to privacy and to refuse medical treatment. Id., at 1104. The court then weighed the state's interests in preserving life, preventing suicide, protecting third parties, maintaining the ethics of the medical profession, and maintaining order in the prison. Id., at 1105. On the facts of the case, the court stated that "although the state interest in the preservation of life is powerful, in and of itself, it will not foreclose a competent person from declining life-sustaining medical treatment.... This is because the life that the state is seeking to protect is the life of the same person who has competently decided to [forgo] the medical intervention." (Citation omitted.) Id., at 1109. The court found it important, also, that the prisoner had expressly stated that he did not want to die, meaning that the state's interest in preventing suicide was not implicated. Id. Finally, no evidence was offered on the other factors; therefore, the court denied the state's petition."

"Nasogastric/Orogastric Tube Placement Indications: * Pre-term: immature suck swallow reflex * Neurological disease: impaired sucking reflex * Respiratory support: increased tachypnea with risk of aspiration * Gastric decompression * NEC * Abdominal surgery"

"Nasogastric tubes should be used preferentially except under conditions below where orogastric tubes may need to be placed: *Nasal prong CPAP *Choanal atresia *Respiratory distress respirations >60bpm grunting recession *Babies with an oxygen requirement *Nasal trauma *Cranio-facial anomalies"

"Follow the steps to measure the correct length of tube required and ensure the baby's comfort. 1.Measure the distance from either the nostril or the mouth (depending on insertion site) to the earlobe then to the half way point between the xiphisternum and the umbilicus. 2.Swaddle infant to provide comfort, offer dummy if infant normally has one. 3. Gently check nostrils for patency if inserting nasogastrically. 4. Select the appropriate size gastric tube; size 6 French for the majority of infants, alternatively size 8 French for large infants or those requiring gut drainage. 5. Gently insert the tube in a smooth swift motion, advancing slightly down and towards the ear on that side, to the desired length. Do not force the tube -if resistance is felt or the tube comes back via the mouth or other nostril then the procedure should be stopped to allow the child to recover prior to any further attempts. If a tube is unable to be inserted in after two attempts, a senior nurse colleague may have one further attempt. If still unsuccessful, discontinue procedure, notify medical staff and document same in clinical record."

"Follow the steps below to ensure correct tube placement, and the ongoing safety of the baby is maintained whilst receiving tube feeds. 1.On inserting a new tube verify placement by aspirating gastric contents and test with the pH indicator strips. Correct position is confirmed when the pH reading is less than or equal to 5. Presence of aspirate alone does not guarantee correct placement Note: Some medications, frequent feeds and continuous feeding may alter the pH and/or the colour of the aspirate e.g. acid inhibiting medications. If pH is >5 or there is difficulty in obtaining aspirate, follow the NPSA Decision tree for nasogastric tube placement checks in Children and Infants. The ‘whoosh’ test (injecting air down the tube and listening) is no longer considered safe practice and should not be used to confirm correct tube placement. 2. Record citing of tube, including internal length and pH in the child’s care map and observation chart. 3. Ensure tube remains in correct position by visually checking the tube position, and checking the aspirate with pH strips prior to each bolus feed or administration of any oral medications. This should be recorded in the feeding section of the observation charts. Note: The tube does not need to be fully aspirated prior to each feed, only enough to pH test, or if there is significant abdominal distention from air which needs aspirating. Infants on continuous feeds should have the position of the tube visualised every hour with routine observations, and pH tested every 4 hours with bottle/syringe changes. 4. Secure the tube using duoderm and hypafix tape placed either on the cheek or chin, and ensure this is firmly attached to the tube. 5. Continually assess feeding tolerance. Observe for vomiting, painful and firm abdominal distension, abdominal discolouration, abnormal bowel sounds, blood in stools, haemorrhagic or heavily bile stained (spinach or avocado) gastric aspirate during pH check. Seek medical review if there is any suspicion of feed intolerance. 6. If findings are not reassuring on medical review then feeds should be withheld. Start gastric decompression, consider further investigation and management for suspected NEC, discuss a feeding plan at the next ward round. 7. Ensure infants who are NBM have their gastric tubes on free drainage with the free end of the tube draining into a specimen pot. Do not attach the syringe connected to the gastric tube to the lid of the incubator. For infants on respiratory support, consider aspirating air from the stomach before each feed. 8. Tubes should be routinely replaced every 2 weeks. Note: if the gastric tube is not to be removed this should be recorded clearly on the observation chart and in the clinical notes (e.g. post TOF repair – see surgical guideline)"

"Trans-pyloric feeding All infants with a trans-pyloric feeding tube require a gastric tube in place for aspiration, potentially drainage and possible medication administration (consult the Pharmacist or Neonatologist involved). Trans-pyloric tubes may be on free drainage but are not used for regular aspiration. Indications *Infants who are not tolerating gastric feeds. *Duodenal atresia - post-operatively *Infants who are at great risk for aspiration, e.g. gastro-oesophageal reflux receiving CPAP. Risk is minimised because the end of the tube is beyond the pyloric sphincter. Complications *Aspiration *Difficulty with tube placement *Perforation of the gut *Malabsorption Considerations *Trans-pyloric feeding may induce symptoms of malabsorption because the stomach is not able to aid in digestion e.g. frequent bowel motion, slow weight gain, necrotising enterocolitis. *Consider where medication is absorbed prior to administration (i.e. stomach or small intestines)"

"Trans-pyloric tube placement Follow the steps below for placement of trans-pyloric tube. 1. A weighted tube is required for trans-pyloric placement (white Vygon paediatric duodenal tube with weighted tip, 6 Fr or Corpak Jejunal weighted tube). These do not harden over time and may be left in situ for several weeks. 2. Length for tube insertion is measured from as per gastric placement with a further length from the xiphoid to the left or right costal margin. 3. The tube is allowed to cool in the refrigerator for an hour; this reduces the chance of it coiling during insertion. 4. Swaddle infant to provide comfort 5. With the infant lying supine at a 15o-40o angle, insert the tube to the stomach as normal. 6. Check stomach positioning by aspirating and testing on a pH strip (reading of 5 or less) 7. Place the infant into a right lateral position 8. Advance the tube 1 cm at a time while instilling up to 2-3 ml of air and auscultate the abdomen 9. Transpyloric placement is characterised by high pitch crackles and the inability to withdraw air ('snap test') 10. Insert further length (as measured) to ensure distal duodenal or proximal jejunal placement. 11. Give a 3 ml feed and remove stylet (if present with brand). 12. The infant should then be placed right side down for 1-1.5 hours 13. Confirmation of placement will then be made by a radiograph. 14. Secure tubing to infant's cheek in same manner as gastric tubes 15. Insertion should be documented in the infant's caremap (equipment section) and in the clinical notes"

"Commencing continuous Gastric or Trans-pyloric feeding Continuous feeding should only be instituted once the infant has reached volumes of at least 7 ml/hr, or on discussion with Neonatologist. This restriction is to avoid the need to purge the tubing every 4 hr with the change of bottle that would be required for lower rates (due to safe hang times). Follow the steps below for commencing continuous Gastric or Jejunal feeding: 1. Draw up prescribed volume of milk. 2. Label with type of milk, date and time. 3. Ensure the correct procedure for setting up the continuous feed pump is observed. 4. Check that the tube is in the correct position and the tape is secure (observe hourly). 5. Commence continuous feed 6. Aspirate gastric tube at least once per shift to confirm placement and determine residual volume"

"Follow the steps below to ensure the nutritional needs of the baby are met. 1. Check that the correct ml/kg are calculated daily 2. Infant's weight is updated as ordered and documented. 3. Observe for spills and abdominal distension. 4. Accurate intake is recorded hourly. 5. Ensure correct type of milk is given and documented. 6. Ensure the amount of EBM/milk mixture in the bottle is recorded"

"Follow the steps below to ensure the safety of the infant is maintained. *That the correct hourly rate on the continuous feed pump is maintained *The total volume infused is accurate. *Two nurses check and sign on the balance sheet each time rate is changed and at the change of shift. *The tubing is changed every 24 hours and labelled clearly with date, time and EBM/NIF. *Ensures that the trans-pyloric tube is not aspirated unless on Doctor's/NS-ANP's orders. *Gastric tube is aspirated 6 hourly and documented. *Administer medication as prescribed by disconnecting at the junction of the trans-pyloric tube and the pump tubing or as per medical staff/NS-ANP instruction (be aware of where of where medication is absorbed) *Only use four hours worth of milk at a time (unless otherwise specified on the bottle label)"

"If an infant is expected to require long term gastric feeding the parents need to be taught care and insertion techniques prior to discharge. See Parent information. 1. Prior to tube insertion the tube must be lubricated with water. 2. Measure length of tube as for short term gastric tubes. 3. Ensure that the cap is on the medication port of the Corpak long term feeding tube. 4. Insert long term feeding tube as for short term tubes. 5. Remove stylet once inserted. 6. Establish gastric placement by aspirating stomach contents and testing on pH strips. A reading of 5 or less should be apparent when touched with stomach fluid. 7. If unable to aspirate fluid then push 1-2 ml of air with a 50 ml syringe. Listen with a stethoscope on the baby's stomach. You should hear a 'whoosh' of air. 8. Secure tube to face with duoderm base and hypafix on top. 9. Flush tube with 3 ml of water using 50 ml syringe. 10. Rinse stylet with warm soapy water and save for future use."

"Follow the steps below for commencing feeds via a long term tube. 1. Warm milk in a bottle and bowl of warm water as usual. 2. If the infant is in a cot pick them up for feeds and utilise a pacifier for non-nutritive sucking if appropriate 3. Connect a 50 ml syringe to the long term feeding tube and pour feed into syringe. 4. Adjust the flow of the feed by raising or lowering the height of the syringe. 5. When finished flush the tube with 3 ml of sterile water via 50 ml syringe. 6. Close tube. Note: USE ONLY A 50 ML SYRINGE TO ADMINISTER ANY MILK OR MEDICATION. The higher pressure of the smaller syringes has potential to perforate the tube."

"Short term enteral feeding in NICU *The optimal care is for all babies to receive breast milk only. This addresses those infants who do not need IV fluids and whose mothers have not established a breast milk supply. *In general, IV infusions should not be started if there are no medical indications for IV fluids (such as respiratory distress, hypoglycaemia etc.) *Babies who need feeding should be given what mother's breast milk is available and always receive mother's breast milk in preference to formula. Be sure to check that no breast milk is available before considering infant formula. *If they require additional feeds, infants should then be started on term infant formula, after discussion with their mother/father. In such discussions, parents should be informed that there are few - if any - adverse effects of formula used short term in this way in a neonatal unit. *For a baby who is already on an IV infusion, it is reasonable to continue the infusion for a short time if mother's milk supply is being established and there is a reasonable expectation that she will be producing enough breast milk with in a day or so. This time period needs to be judged against the ease of IV access and the condition of the baby. Babies should not have IVs re-inserted solely because no breast milk is available. *Smaller preterm infants will often have a medical indication for ongoing IV fluids and in them it is desirable to increase the oral fluids slowly. The pace of increase of oral fluids can usually be matched to the increase in the availability of expressed breast milk. *Mothers should be advised and helped with expressing. NICU staff should discuss expressing as soon as possible. It is accepted that the role of initially helping with expressing lies with postnatal ward staff. NICU staff should support mothers' expression of breast milk. *Nasogastric feeding rather than bottle or cup feeding is advantageous for ex-premature babies. Term babies who do not have problems with hypoglycaemia can usually transition directly from IV fluids to breast feeds. Alternatively, bottle or tube feeds may be used for larger infants. *NICU does not provide hydrolysed formula unless there is a clinical indication (other than a history of allergy). If there is a very strong family history of allergy, hydrolysed formula may be supplied on an individual basis. Parents may supply their own formula (hydrolysed or non-cow's milk preparations) if they wish."

"In recent years, two hunger strikes by prisoners received extensive international attention, in part because a number of prisoners died during the protests: the 1981 hunger strike by Irish prisoners in Maze prison during which ten prisoners died, and the hunger strike by Turkish political prisoners in the summer of 1996 during which at least twelve prisoners died and numerous others suffered neurological and psychiatric problems. When the ICRC visited Maze prison in Ulster, the ICRC team members became very concerned despite the fact that, unlike at Guantánamo, medical personnel were authorized to see the hunger strikers and permitted to maintain close communication with the prisoners’ families: “‘[O]utside intervention’ was totally unacceptable in the (northern) Irish hunger strikes of 1980 and 1981. Although the ICRC sent a team with a medical doctor to see the fasting prisoners (as was widely reported in the press at the time), the hunger strikers in this case refused to accept any outside medical mediation. As soon became clear, the hunger strikes in Ulster were deadly serious, with a total of ten prisoners dying over several months. The prison doctors respected the expressed will of the hunger strikers, and force-feeding was not envisaged at any time. (This position based on respect for a patient’s integrity and his right to refuse treatment, was the exact opposite of the attitude held earlier in the century, when political hunger strikers were force-fed by court order in 1909). In the Irish strike, the prisoners’ families were very much involved and communicated with the prison doctors. In a few cases, it was the families of prisoners who asked doctors to intervene at an advanced stage to save their sons’ lives, a request that was complied with. The bottom line in the doctors’ position was that a prisoner’s express will (not to be nourished) would be respected as long as he was fit to decide, but that families could obtain medical assistance for their fasting relatives if [the prisoners] were no longer in a position to express refusal. (This sometimes led to bitter arguments, with some hunger strikers telling their families they would never forgive them if they broke the strike by asking for medical assistance on their behalf. Most families, in fact, supported their sons or husbands on the strike.)"

"The ICRC’s observation of the Irish prisoners’ protest also emphasizes the ethical issues for medical providers raised by hunger strikes in prison facilities, particularly concerning the issue of force-feeding such prisoners. As is widely known, the World Medical Association (WMA) Declaration of Tokyo of 1975 prohibits a medical doctor’s participation in torture, whether actively, passively, or through the use of medical knowledge. Article 5 of the Tokyo Declaration also stipulates that prisoners on hunger strikes shall not be force-fed. According to Dr. André Wynen, former and Honorary Secretary-General and founding member of the WMA, Article 5 of the Tokyo Declaration relates to the declaration’s prohibition on medical providers’ involvement intorture. “If a prisoner undergoing torture decided to protest against his plight by going on a hunger strike, a doctor should not be obliged to administer nourishment against the prisoner’s will and thereby effectively revive him for more torture.” The WMA supplemented Article 5 of the Tokyo Declaration with the 1991 Declaration of Malta. The Malta Declaration also prohibits force-feeding, but stipulates that doctors should ultimately act for the benefit of their patients when the prisoner’s detention does not raise concerns about physician involvement in torture and the hunger striker is no longer capable of sound judgment because of the effects of long-term fasting."